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Below is a summary of the current and new State of SC Health Plan Coverage Rules and
traditional prior authorization. The plan will cover the following quantities of medication within
the specified period of time.
Drug name: Use: Coverage:
Sumatriptan (brand Migraine The plan will cover nine of the 100, eighteen of
name Imatrex®) Management the 50 mg or eighteen of the 25 mg tablets within
a 30-day period of time OR The plan will cover
sixteen of the 5 mg or eight of the 20 mg nasal
spray devices within a 30-day period of time OR
The plan will cover 4 of the injection kits within
a 30-day period of time (triple quantities for
home delivery). Larger quantities require
coverage review.
Zolmitriptan (brand Migraine The plan will cover eight of the 5 mg or eight of
name Zomig®) Management the 2.5 mg tablets within a 30-day period of time
(triple quantities for home delivery). Larger
quantities require coverage review.
Naratriptan (brand Migraine The plan will cover eight of the 1 mg or eight of
name Amerge®) Management the 2.5 mg tablets within a 30-day period of time
(triple quantities for home delivery). Larger
quantities require coverage review.
Almotriptan (brand Migraine The plan will cover eight of the 6.25 mg or eight
name Axert®) Management of the 12.5 mg tablets within a 30-day period of
time (triple quantities for home delivery). Larger
quantities require coverage review.
Frovatriptan (brand Migraine The plan will cover twelve of the 2.5 mg tablets
name Frova®) Management within a 30-day period of time (triple quantities
for home delivery). Larger quantities require
coverage review.
Eletriptan (brand Migraine The plan will cover eight of the 20 mg or eight of
name Relpax®) Management the 40 mg tablets within a 30-day period of time
(triple quantities for home delivery). Larger
quantities require coverage review.
Rizatriptan (brand Migraine The plan will cover twelve of the 10 mg tablets
name Maxalt®, Management or twenty-four of the 5 mg tablets within a 30-
Maxalt-MLT®) day period of time (triple quantities for home
delivery). Larger quantities require coverage
review.
Dihydroergotamine Migraine The plan will cover eight ampules of nasal spray
(brand name Migranal Management within a 30-day period of time (24 at home
NS®) delivery). Larger quantities require coverage
review.
Butorphanol (brand Analgesics – Misc. The plan will cover 4 canisters of nasal spray
name Stadol NS®) within a 30-day period of time (12 at home
delivery. Larger quantities requires a coverage
review.
Fluconazole 150 mg Antifungal - The plan will cover two fluconazole 150 mg
tablet (brand name Vaginitis tablets within a rolling 30-day period of time.
Diflucan®) No exceptions though coverage review.
Lansoprazole (brand Gastrintestinal – Allows only 90 days “acute (high) dose therapy”
name Prevacid®) Antisecretory within the last 150 days without coverage review.
Management – “Actute therapy” defined as: >30 mg/day of
Proton Pump Prevacid. Higher doses for longer require a
Inhibitors coverage review.
Zaleplon (brand name Hypnotic Agents The plan will cover a total of 60 days of either
Sonata®) medication, or a combination of the two
medications adding up to 60 days, within a 90-
day period of time. Larger quantity requires
coverage review.
Zolpidem (brand Hypnotic Agents The plan will cover a total of 60 days of either
name Ambien®) medication, or a combination of the two
medications adding up to 60 days, within a 90-
day period of time. Larger quantity requires
coverage review.
Bupropion (brand Smoking Deterrent The plan will cover 1 treatment course (90-day
name Zyban®) supply) within one 365-day period of time. No
exceptions through coverage review.
Oseltamivir (brand Anti-infectives - The plan will cover 1 treatment course (10
name Tamiflu®) influenza capsules or 100 mls = 5-day supply) within 180-
day period of time. Coverage review required
for exceptions.
Zanamivir (brand Anti-infectives - The plan will cover 1 treatment course (20 units
name Relenza®) influenza = 5-day supply) within 180-day period of time.
Coverage review required for exceptions.
Celecoxib (brand Analgesics - COX- Allows coverage if patient is >65 years of age or
name Celebrex®) 2 Inhibitor has an “active” prescription in history for
Celebrex, Vioxx, Bextra, anticoagulants,
antiplatelet agents, anti-ulcer agent, or oral
glucocorticosteroids, if not coverage review
required.
Rofecoxib (brand Analgesics - COX- Allows coverage if patient is >65 years of age or
name Vioxx®) 2 Inhibitor has an “active” prescription in history for
Withdrawn from Celebrex, Vioxx, Bextra, anticoagulants,
Market 09/30/04 antiplatelet agents, anti-ulcer agent, or oral
glucocorticosteroids, if not coverage review
required.
Valdecoxib (brand Analgesics - COX- >65 years of age or has an “active” prescription
name Bextra®) 2 Inhibitor in history for Celebrex, Vioxx, Bextra,
anticoagulants, antiplatelet agents, anti-ulcer
agent, or oral glucocorticosteroids, if not
coverage review required.
Fexofenadine (brand Respiratory – Allows coverage if patient is <16 years of age or
name Allegra®, Allergy – Non- has a prescription in history for a non-sedating
Allegra-D®) Sedating antihistamine, intranasal corticosteroid, or oral
Antihistamines corticosteroid (<15-day supply within last 30
days), if not, then coverage review required. Not
covered in Savings Plan.
Desloratidine (brand Respiratory – Allows coverage if patient is <16 years of age or
name Clarinex®) Allergy – Non- has a prescription in history for a non-sedating
Sedating antihistamine, intranasal corticosteroid, or oral
Antihistamines corticosteroid (<15-day supply within last 30
days), if not, then coverage review required. Not
covered in Savings Plan.
Celirizine (brand Respiratory – Allows coverage if patient is <16 years of age or
name Zyrtec® and Allergy – Non- has a prescription in history for a non-sedating
Zyrtec-D®) Sedating antihistamine, intranasal corticosteroid, or oral
Antihistamines corticosteroid (<15-day supply within last 30
days), if not, then coverage review required. Not
covered in Savings Plan.
Montelukast (brand Respiratory – Allows coverage if patient is <16 years of age or
name Singulair®) Allergy – Non- has a prescription in history for a leukotrine
Sedating inhibitor, intranasal corticosteroid, orally inhaled
Antihistamines corticosteroid or asthma medication, if not, then
coverage review required.
Zafirlukast (brand Respiratory – Allows coverage if patient is <16 years of age or
name Accolate®) Allergy – Non- has a prescription in history for a leukotrine
Sedating inhibitor, intranasal corticosteroid, orally inhaled
Antihistamines corticosteroid or asthma medication, if not, then
coverage review required.
Zilenton (brand name Respiratory – Allows coverage if patient is <16 years of age or
Zyflo®) Allergy – Non- has a prescription in history for a leukotrine
Sedating inhibitor, intranasal corticosteroid, orally inhaled
Antihistamines corticosteroid or asthma medication, if not, then
coverage review required.
Terbinafine (brand Antifungals - Nail The plan will cover ninety of the 250 mg tablets
name Lamisil®) Infection within a 180-day period of time. If claims in
Management history indicating immunosuppression, greater
quantities allowed without coverage review.
Otherwise coverage review is required.
Itraconazole (brand Antifungals - Nail The plan will cover 180 of the 100 mg capsules
name Sporonox®) Infection within a 180-day period of time. If claims in
Management history indicating immunosuppression, greater
quantities allowed without coverage review.
Otherwise coverage review is required.
Fluconazole (brand Antifungals - Nail The plan will cover 144 of the 50 mg tablets
name Diflucan®) Infection within a 180-day period of time OR The plan
Management will cover 72 of the 100 mg tablets within a 180-
day period of time OR The plan will cover 36 of
the 200 mg tablets within a 180-day period of
time. If claims in history indicating
immunosuppression, greater quantities allowed
without coverage review. Otherwise coverage
review is required.
Retin A, Avita, Dermatology - Prior authorization required.
generics, Accutane Acne
Contraceptive Agents Contraception Dependents require prior authorization for
(orals, patches and coverage. Only covered for medical indications
injectables) for dependents (not contraception).
Sildenafil (brand Impotence Prior authorization required. Once approved,
name Viagra®) Management plan allows 8 tabs within 30 days (24 at home
delivery). Not covered for Savings Plan.
Tadalafil (brand name Impotence Prior authorization required. Once approved,
Cialis®) Management plan allows 8 tabs within 30 days (24 at home
delivery). Not covered for Savings Plan.
Vardenafil (brand Impotence Prior authorization required. Once approved,
name Levitra®) Management plan allows 8 tabs within 30 days (24 at home
delivery). Not covered for Savings Plan.
Alprostadil (brand Impotence Prior authorization required. Once approved,
name Caverject, Edex, Management plan allows 8 tabs within 30 days (24 at home
and Muse®) delivery). Not covered for Savings Plan.
These quantities are based on usual treatment recommendations, should the physician feel that
there are circumstances that may qualify the patient for additional quantities of medication in
excess of the quantities listed above, the doctor of pharmacist may request a coverage review by
contacting Merck-Medco at 800-753-2851.
